﻿#parse("partials/header.html") #parse("partials/sidebar.html")
<script src="${rooturl}Scripts/FrontOffice/patientregistration.js" type="text/javascript"></script>
<script src="${rooturl}Scripts/ajaxupload.js" type="text/javascript"></script>
<style> 
    .no-close .ui-dialog-titlebar-close {display: none }
</style>
<!-- Main Container Start -->
<div id="mws-container" class="clearfix">
    <!-- Inner Container Start -->
    <div class="container">
        <!-- Panels Start -->
        <form method="post" action="$Actionform" class="crud" id="mws-validate">
        <div class="mws-panel grid_8 mws-collapsible">
            <div class="title-caption">
                <h5>
                    $headerinformation - $Lob - Patient Registration</h5>
            </div>
            <div class="mws-panel-header">
                <span class="mws-i-24 i-calendar-today">Patient Data Registration Form</span>
            </div>
            <div class="mws-panel-body">
                <div class="mws-panel-toolbar top clearfix">
                    <ul>
                        <li><a class="mws-ic-16 ic-application-view-list" href="/frontoffice/lobselection/?redirectUri=patientdata/default" title="Search">Select LOB</a></li>
                        <li><a class="mws-ic-16 ic-application-view-list" href="/patientdata/default" title="Search">
                            Search Patient</a></li>
                        <li><a class="mws-ic-16 ic-application-view-list" href="/frontoffice/registration/searchdoctor"
                            title="Search">Doctor List </a></li>
                        <li><a class="mws-ic-16 ic-application-view-list" href="/frontoffice/registration/searchappointment"
                            title="Search">Appointment List </a></li>
                        <li><a class="mws-ic-16 ic-add" href="/patientdata/default/patientdetail" title="Add">
                            New Patient Data Registration</a></li>
                        <!--<li><a class="mws-ic-16 ic-accept" href="/frontoffice/registration/registrationlist"
                            title="Accept">Registration List</a></li>-->
                    </ul>
                </div>
                <div id="notif">
                    $Notification
                </div>
                <div class="mws-form">
                    <div class="grid_4">
                        <div class="mws-form-inline">
                            <!-- <div class="mws-form-row">
                                <label>
                                    Out Patient No.</label>
                                <div class="mws-form-item">
                                    <input id="CodeValue" name="CodeValue" value="$oPatientRegistration.CodeValue" type="text"
                                        class="mws-textinput" readonly="readonly" />
                                </div>
                            </div>-->
                            <div class="mws-form-row">
                                <label>
                                    Medical Record No.</label>
                                <div class="mws-form-item">
                                    <input id="" name="" value="$oPatient.MedicalRecordNumber" type="text" class="mws-textinput"
                                        disabled="disabled" />
                                    <input id="MedicalRecordNumber" name="MedicalRecordNumber" value="$oPatient.MedicalRecordNumber"
                                        type="hidden" />
                                    <input type="hidden" id="PatientId" name="Id" value="$oPatient.Id" />
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Patient Name <span style="color: #FF0000; font-size: medium;">*</span>
                                </label>
                                <div class="mws-form-item large">
                                    <div class="mws-form-cols clearfix">
                                        <div class="mws-form-col-3-8 alpha">
                                            <div class="mws-form-item">
                                                $DdSalutation
                                            </div>
                                        </div>
                                        <div class="mws-form-item">
                                            <input name="FirstName" id="FirstName" value="$oPatient.FirstName" type="text" class="mws-textinput required"
                                                maxlength="15" />
                                        </div>
                                    </div>
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Middle Name</label>
                                <div class="mws-form-item">
                                    <input id="MiddleName" name="MiddleName" value="$oPatient.MiddleName" type="text"
                                        class="mws-textinput" maxlength="15" />
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Last Name</label>
                                <div class="mws-form-item">
                                    <input id="LastName" name="LastName" value="$oPatient.LastName" type="text" class="mws-textinput"
                                        maxlength="15" />
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Gender</label>
                                <div class="mws-form-item large">
                                    <div class="mws-form-cols clearfix">
                                        <div class="mws-form-col-5-8 alpha">
                                            <div class="mws-form-item">
                                                <input id="gender" value="$Gender" type="text" class="mws-textinput" readonly="true"
                                                    disabled="disabled" />
                                                <input id="GenderId" value="$oPatient.GenderId" name="GenderId" type="hidden" readonly="true" />
                                            </div>
                                        </div>
                                    </div>
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    DOB 
                                    #if($Lob!="ETC")
                                        <span style="color: #FF0000; font-size: medium;">*</span>
                                    #end
                                </label>
                                <div class="mws-form-item large">
                                    <div class="mws-form-cols clearfix">
                                        <div class="mws-form-col-5-8 alpha">
                                            <div class="mws-form-item">
                                                #if($Lob=="ETC")
                                                <input id="TextBoxDob" name="Birthdate" value="$Birthdate" type="text" class="mws-textinput indonesianDate"
                                                    maxlength="10" />
                                                #else
                                                <input id="TextBoxDob" name="Birthdate" value="$Birthdate" type="text" class="mws-textinput required indonesianDate"
                                                    maxlength="10" />
                                                #end
                                            </div>
                                        </div>
                                        <div class="mws-form-col-3-8 alpha" style="margin-top: 7px;">
                                            (dd/mm/yyyy)
                                        </div>
                                    </div>
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Age</label>
                                <div class="mws-form-item large">
                                    <input id="TextBoxAge" value="$Age" type="text" class="mws-textinput" disabled="disabled"
                                        readonly="readonly" />
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Identity Card</label>
                                <div class="mws-form-item large">
                                    <div class="mws-form-cols clearfix">
                                        <div class="mws-form-col-3-8 alpha">
                                            <div class="mws-form-item">
                                                $DdIdentityCardType
                                            </div>
                                        </div>
                                        <div class="mws-form-col-5-8 alpha" id="divIdentityCardbNumber">
                                            <div class="mws-form-item">
                                                <input name="IdentityCardbNumber" id="IdentityCardbNumber" value="$oPatient.IdentityCardbNumber"
                                                    type="text" class="mws-textinput" maxlength="30" />
                                            </div>
                                        </div>
                                        <div class="mws-form-col-2-8 alpha" id="divButtonPassportDetail" style="display: none">
                                            <div class="mws-form-item">
                                                <input type="button" id="ButtonPassportDetail" class="mws-button green small" value="     Detail     "
                                                    onclick="OpenPopUpPassportDetail2()" style="margin-top: 0;" />
                                                <input type="hidden" id="HiddenPassportId" name="PassportId" value="$oFormPatientPassport.PassportId" />
                                                <input type="hidden" id="HiddenPatientPassportTypeId" name="PatientPassportTypeId"
                                                    value="$oFormPatientPassport.PatientPassportTypeId" />
                                                <input class="mws-textinput" id="PassportCodeValue" name="PassportCodeValue" type="hidden"
                                                    value="$oFormPatientPassport.PassportCodeValue" maxlength="50" />
                                                <input class="mws-textinput mws-datepicker-range2020 indonesianDate" id="PassportIssuedDate"
                                                    name="PassportIssuedDate" type="hidden" value="$oFormPatientPassport.PassportIssuedDate"
                                                    maxlength="10" />
                                                <input class="mws-textinput mws-datepicker-range2020 indonesianDate" id="PassportExpiryDate"
                                                    name="PassportExpiryDate" type="hidden" maxlength="10" value="$oFormPatientPassport.PassportExpiryDate" />
                                                <input class="mws-textinput" id="PassportIssuedAt" name="PassportIssuedAt" type="hidden"
                                                    value="$oFormPatientPassport.PassportIssuedAt" maxlength="50" />
                                                <input class="mws-textinput" id="HPassportNationality" name="PassportNationality"
                                                    type="hidden" value="$oFormPatientPassport.PassportNationality" />
                                                <input type="hidden" id="HiddenVisaId" name="VisaId" value="$oFormPatientVisa.VisaId" />
                                                <input type="hidden" id="HiddenPatientVisaTypeId" name="PatientVisaTypeId" value="$oFormPatientVisa.PatientVisaTypeId" />
                                                <input class="mws-textinput" id="VisaIssuedMe" name="VisaIssuedMe" type="hidden"
                                                    value="$oFormPatientVisa.VisaIssuedMe" maxlength="50" />
                                                <input class="mws-textinput mws-datepicker-range2020 indonesianDate" id="VisaIssuedDate"
                                                    name="VisaIssuedDate" type="hidden" value="$oFormPatientVisa.VisaIssuedDate"
                                                    maxlength="10" />
                                                <input class="mws-textinput mws-datepicker-range2020 indonesianDate" id="VisaExpiryDate"
                                                    name="VisaExpiryDate" type="hidden" value="$oFormPatientVisa.VisaExpiryDate"
                                                    maxlength="10" />
                                                <input class="mws-textinput" id="VisaIssuedBy" name="VisaIssuedBy" type="hidden"
                                                    value="$oFormPatientVisa.VisaIssuedBy" maxlength="50" />
                                                <input type="hidden" id="HiddenVisaIsForeigner" name="VisaIsForeigner" value="$oFormPatientVisa.VisaIsForeigner" />
                                                <input type="hidden" id="HiddenWorkPermitId" name="WorkPermitId" value="$oFormPatientWorkPermit.WorkPermitId" />
                                                <input type="hidden" id="HiddenPatientWorkPermitTypeId" name="PatientWorkPermitTypeId"
                                                    value="$oFormPatientWorkPermit.PatientWorkPermitTypeId" />
                                                <input class="mws-textinput" id="WorkPermitCodeValue" name="WorkPermitCodeValue"
                                                    type="hidden" value="$oFormPatientWorkPermit.WorkPermitCodeValue" maxlength="50" />
                                                <input class="mws-textinput mws-datepicker-range2020 indonesianDate" id="WorkPermitIssuedDate"
                                                    name="WorkPermitIssuedDate" type="hidden" value="$oFormPatientWorkPermit.WorkPermitIssuedDate"
                                                    maxlength="10" />
                                                <input class="mws-textinput mws-datepicker-range2020 indonesianDate" id="WorkPermitExpiryDate"
                                                    name="WorkPermitExpiryDate" type="hidden" value="$oFormPatientWorkPermit.WorkPermitExpiryDate"
                                                    maxlength="10" />
                                                <input class="mws-textinput" id="WorkPermitIssuedBy" name="WorkPermitIssuedBy" type="hidden"
                                                    value="$oFormPatientWorkPermit.WorkPermitIssuedBy" maxlength="50" />
                                            </div>
                                        </div>
                                    </div>
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Occupation</label>
                                <div class="mws-form-item large">
                                    $DdOccupation
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Ethnic</label>
                                $DdEthnic
                            </div>
                        </div>
                    </div>
                    <div class="grid_4">
                        <div class="mws-form-inline">
                            <div class="mws-form-row">
                                <div class="mws-form-item large">
                                    <div id="fileList" style="max-height: 175px; max-width: 150px; border: #F2F2F2 3px solid;">
                                        <img src="$PatientPhoto" style="height: 175px; width: 150px;" />
                                    </div>
                                    <input type="hidden" id="PhotoId" name="PhotoId" value="$PhotoId" />
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Patient Photo</label>
                                <div class="mws-form-item large">
                                    <div class="mws-form-cols clearfix">
                                        <div class="mws-form-col-6-8 alpha">
                                            <div class="mws-form-item">
                                                <!--<input type="file" id="fuOPD" name="fileInput" />-->
                                                <input type="button" id="uploadFile" value="Upload Photo" class="mws-button gray" style="width: 152px;" />
                                            </div>
                                        </div>
                                        <div class="mws-form-item">
                                            <!--<input type="button" id="buttonUpload" value="Upload" class="mws-button gray" />-->
                                            <!--<div id="uploadStatus" style="vertical-align: bottom;"></div>-->
                                        </div>
                                    </div>
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    LOB</label>
                                <div class="mws-form-item large">
                                    <input type="text" class="mws-textinput" readonly="readonly" value="$Lob" disabled="disabled" />
                                </div>
                            </div>
                            <!--<div class="mws-form-row">
                                <label>
                                    Registration Date</label>
                                <div class="mws-form-item large">
                                    <input id="reg_time" name="RegistrationTime" value="" type="text" class="mws-textinput"
                                        readonly="readonly" />
                                </div>
                            </div>-->
                            <div class="mws-form-row">
                                <label>
                                    Place of Birth
                                    #if($Lob!="ETC")
                                         <span style="color: #FF0000; font-size: medium;">*</span>
                                    #end
                                    </label>
                                <div class="mws-form-item large">
                                     #if($Lob=="ETC")
                                        <input name="Birthplace" id="Birthplace" value="$oPatient.Birthplace" type="text"
                                            class="mws-textinput" maxlength="50" />
                                     #else
                                        <input name="Birthplace" id="Birthplace" value="$oPatient.Birthplace" type="text"
                                            class="mws-textinput required" maxlength="50" />
                                     #end
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Blood Group 
                                    #if($Lob!="ETC")
                                    <span style="color: #FF0000; font-size: medium;">*</span>  
                                    #end
                                    </label>
                                    
                                <div class="mws-form-item large">
                                    <div class="mws-form-cols clearfix">
                                        <div class="mws-form-col-3-8 alpha">
                                            <div class="mws-form-item">
                                            #if($Lob=="ETC")
                                                $DdBloodTypeNotRequired
                                            #else
                                                $DdBloodType
                                            #end
                                                
                                            </div>
                                        </div>
                                    </div>
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Weight 
                                    #if($Lob!="ETC")
                                    <span style="color: #FF0000; font-size: medium;">*</span> 
                                    #end
                                </label>
                                <div class="mws-form-item large">
                                    <div class="mws-form-cols clearfix">
                                        <div class="mws-form-col-4-8 alpha">
                                        #if($Lob=="ETC")
                                            <input name="Weight" id="Weight" type="text" class="mws-textinput" maxlength="6"
                                                value="$Weight" />
                                        #else
                                            <input name="Weight" id="Weight" type="text" class="mws-textinput required" maxlength="6"
                                                value="$Weight" />
                                        #end
                                        </div>
                                        <div class="mws-form-col-1-8 alpha" style="margin-top: 3px;">
                                            Kg
                                        </div>
                                    </div>
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Height 
                                    #if($Lob!="ETC")
                                    <span style="color: #FF0000; font-size: medium;">*</span>  
                                    #end
                                    </label>
                                    
                                <div class="mws-form-item large">
                                    <div class="mws-form-cols clearfix">
                                        <div class="mws-form-col-4-8 alpha">
                                            #if($Lob=="ETC")
                                                <input id="Height" name="Height" type="text" class="mws-textinput" maxlength="6" value="$Height" />
                                            #else
                                                <input id="Height" name="Height" type="text" class="mws-textinput required" maxlength="6" value="$Height" />
                                            #end
                                        </div>
                                        <div class="mws-form-col-1-8 alpha" style="margin-top: 3px;">
                                            Cm
                                        </div>
                                    </div>
                                </div>
                            </div>
                        </div>
                    </div>
                    <div class="clear">
                    </div>
                    <div class="grid_8">
                        <div class="mws-accordion">
                            <h3>
                                <a href="#">Address</a></h3>
                            <div class="mws-accordion-445">
                                <div class="grid_4">
                                    <h5>
                                        Present Address</h5>
                                    <div class="mws-form-inline">
                                        <div class="mws-form-row">
                                            <label>
                                                Address 
                                                #if($Lob!="ETC")
                                                <span style="color: #FF0000; font-size: medium;">*</span>
                                                #end
                                            </label>
                                            <div class="mws-form-item">
                                                #if($Lob=="ETC")
                                                <input id="TextBoxAddressDescPresent" name="PresentAddressDesc" value="$oFormPresentAddress.PresentAddressDesc"
                                                    type="text" class="mws-textinput" />
                                                #else
                                                <input id="TextBoxAddressDescPresent" name="PresentAddressDesc" value="$oFormPresentAddress.PresentAddressDesc"
                                                    type="text" class="mws-textinput required" />
                                                #end
                                                <input type="hidden" id="HiddenPresentAddressId" name="HiddenPresentAddressId" value="$oFormPresentAddress.HiddenPresentAddressId" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Area</label>
                                            <div class="mws-form-item">
                                                <div class="mws-form-cols clearfix">
                                                    <div class="mws-form-col-6-8 alpha">
                                                        <div class="mws-form-item">
                                                            <input id="TextBoxAreaPresent" name="PresentAreaName" value="$oFormPresentAddress.PresentAreaName"
                                                                type="text" class="mws-textinput" readonly="readonly" style="background-color: #F2F2F2;" />
                                                            <input id="HiddenPresentAddressAreaId" type="hidden" name="HiddenPresentAddressAreaId"
                                                                value="$oFormPresentAddress.HiddenPresentAddressAreaId" />
                                                        </div>
                                                    </div>
                                                    <div class="mws-form-col-2-8">
                                                        <div class="mws-form-item">
                                                            <input type="button" class="mws-button green small ButtonSearchPresentArea" addresstype="present"
                                                                name="ButtonSearchPresentArea" value="   Search   " onclick="OpenPopUpPresentArea()"
                                                                style="margin-top: 0; width: 77px;" />
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                City</label>
                                            <div class="mws-form-item">
                                                <input id="TextBoxCityPresent" name="PresentCityName" value="$oFormPresentAddress.PresentCityName"
                                                    type="text" class="mws-textinput" readonly="readonly" style="background-color: #F2F2F2;" />
                                                <input id="HiddenPresentAddressCityId" type="hidden" name="HiddenPresentAddressCityId"
                                                    value="$oFormPresentAddress.HiddenPresentAddressCityId" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Province</label>
                                            <div class="mws-form-item">
                                                <input id="TextBoxStatePresent" value="$oFormPresentAddress.PresentProvinceName"
                                                    name="PresentProvinceName" type="text" class="mws-textinput" readonly="readonly"
                                                    style="background-color: #F2F2F2;" />
                                                <input id="HiddenPresentProvinceId" name="HiddenPresentProvinceId" type="hidden"
                                                    value="$oFormPresentAddress.HiddenPresentProvinceId" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Country</label>
                                            <div class="mws-form-item">
                                                <input id="TextBoxCountryPresent" name="PresentCountryName" value="$oFormPresentAddress.PresentCountryName"
                                                    type="text" class="mws-textinput" readonly="readonly" style="background-color: #F2F2F2;" />
                                                <input id="HiddenPresentAddressCountryId" name="HiddenPresentAddressCountryId" type="hidden"
                                                    value="$oFormPresentAddress.HiddenPresentAddressCountryId" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                PIN/ZIP/Code</label>
                                            <div class="mws-form-item">
                                                <input id="TextBoxZipCodePresent" name="PresentZipCode" type="text" class="mws-textinput"
                                                    value="$oFormPresentAddress.PresentZipCode" maxlength="10" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Phone Number
                                            </label>
                                            <div class="mws-form-item large">
                                                <input id="TextBoxPhoneNumberPresent" name="PresentPhoneNumber" type="text" class="mws-textinput digits"
                                                    value="$oFormPresentAddress.PresentPhoneNumber" maxlength="15" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <div class="mws-form-item" align="right">
                                                <input name="buttonResetPresAddr" id="buttonResetPresAddr" type="button" value="Reset Present Address"
                                                    class="mws-button gray" onclick="ResetPresentAddress()" />
                                            </div>
                                        </div>
                                    </div>
                                </div>
                                <div class="grid_4">
                                    <div class="grid_4">
                                        <h5>
                                            Permanent Address</h5>
                                    </div>
                                    <div class="grid_4">
                                        <input id="CheckboxPermanentAddress" type="checkbox" />
                                        <label>
                                            Same as Present</label>
                                    </div>
                                    <div class="clear">
                                    </div>
                                    <div class="mws-form-inline">
                                        <div class="mws-form-row">
                                            <label>
                                                Address</label>
                                            <div class="mws-form-item">
                                                <input id="TextBoxAddressDescPermanent" name="PermanentAddressDesc" value="$oFormPermanentAddress.PermanentAddressDesc"
                                                    type="text" class="mws-textinput" />
                                                <input type="hidden" id="HiddenPermanentAddressId" name="HiddenPermanentAddressId"
                                                    value="$oFormPermanentAddress.HiddenPermanentAddressId" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Area</label>
                                            <div class="mws-form-item">
                                                <div class="mws-form-cols clearfix">
                                                    <div class="mws-form-col-6-8 alpha">
                                                        <div class="mws-form-item">
                                                            <input id="TextBoxAreaPermanent" name="PermanentAreaName" value="$oFormPermanentAddress.PermanentAreaName"
                                                                type="text" class="mws-textinput" readonly="readonly" style="background-color: #F2F2F2;" />
                                                            <input id="HiddenPermanentAddressAreaId" type="hidden" name="HiddenPermanentAddressAreaId"
                                                                value="$oFormPermanentAddress.HiddenPermanentAddressAreaId" />
                                                        </div>
                                                    </div>
                                                    <div class="mws-form-col-2-8">
                                                        <div class="mws-form-item">
                                                            <input type="button" id="mws-form-dialog-mdl-btn" addresstype="permanent" name="ButtonSearchPermanentArea"
                                                                class="mws-button green small" value="   Search   " onclick="OpenPopUpPermanentArea()"
                                                                style="margin-top: 0; width: 77px;" />
                                                            <input id="HiddenIsPermanentAddress" type="hidden" />
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                City</label>
                                            <div class="mws-form-item">
                                                <input id="TextBoxCityPermanent" name="PermanentCityName" value="$oFormPermanentAddress.PermanentCityName"
                                                    type="text" class="mws-textinput" readonly="readonly" style="background-color: #F2F2F2;" />
                                                <input id="HiddenPermanentAddressCityId" type="hidden" name="HiddenPermanentAddressCityId"
                                                    value="$oFormPermanentAddress.HiddenPermanentAddressCityId" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Province</label>
                                            <div class="mws-form-item">
                                                <input id="TextBoxStatePermanent" value="$oFormPermanentAddress.PermanentProvinceName"
                                                    name="PermanentProvinceName" type="text" class="mws-textinput" readonly="readonly"
                                                    style="background-color: #F2F2F2;" />
                                                <input id="HiddenPermanentProvinceId" name="HiddenPermanentProvinceId" type="hidden"
                                                    value="$oFormPermanentAddress.HiddenPermanentProvinceId" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Country</label>
                                            <div class="mws-form-item">
                                                <input id="TextBoxCountryPermanent" name="PermanentCountryName" value="$oFormPermanentAddress.PermanentCountryName"
                                                    type="text" class="mws-textinput" readonly="readonly" style="background-color: #F2F2F2;" />
                                                <input id="HiddenPermanentAddressCountryId" name="HiddenPermanentAddressCountryId"
                                                    value="$oFormPermanentAddress.HiddenPermanentAddressCountryId" type="hidden" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                PIN/ZIP/Code</label>
                                            <div class="mws-form-item">
                                                <input id="TextBoxZipCodePermanent" name="PermanentZipCode" value="$oFormPermanentAddress.PermanentZipCode"
                                                    type="text" class="mws-textinput" maxlength="10" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Phone Number</label>
                                            <div class="mws-form-item large">
                                                <input id="TextBoxPhoneNumberPermanent" name="PermanentPhoneNumber" value="$oFormPermanentAddress.PermanentPhoneNumber"
                                                    type="text" class="mws-textinput digits" maxlength="20" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <div class="mws-form-item" align="right">
                                                <input name="buttonResetPermAddr" id="buttonResetPermAddr" type="button" value="Reset Permanent Address"
                                                    class="mws-button gray" onclick="ResetPermanentAddress()" />
                                            </div>
                                        </div>
                                    </div>
                                </div>
                                <hr />
                                <div class="grid_4">
                                    <div class="mws-form-inline">
                                        <div class="mws-form-row">
                                            <label>
                                                Mobile Phone 
                                                #if($Lob!="ETC")
                                                <span style="color: #FF0000; font-size: medium;">*</span>
                                                #end
                                            </label>
                                            <div class="mws-form-item large">
                                                #if($Lob=="ETC")
                                                <input id="PhoneNumber" name="PhoneNumber" value="$oPatient.PhoneNumber" type="text"
                                                    class="mws-textinput" maxlength="20" />
                                                #else
                                                    <input id="PhoneNumber" name="PhoneNumber" value="$oPatient.PhoneNumber" type="text"
                                                    class="mws-textinput required" maxlength="20" />
                                                #end
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Email ID</label>
                                            <div class="mws-form-item large">
                                                <input name="Email" value="$oPatient.Email" type="text" class="mws-textinput email" />
                                            </div>
                                        </div>
                                       
                                    </div>
                                </div>
                                <div class="grid_4">
                                    <div class="mws-form-inline">
                                       
                                        <div class="mws-form-row">
                                           
                                            <label>
                                            </label>
                                        </div>
                                    </div>
                                </div>
                            </div>
                            <h3>
                                <a href="#">Additional Profile</a></h3>
                            <div class="mws-accordion-215">
                                <div class="grid_4">
                                    <div class="mws-form-inline">
                                        <div class="mws-form-row">
                                            <label>
                                                Father Name</label>
                                            <div class="mws-form-item">
                                                <input name="Fathername" value="$oFormPatientRelative.Fathername" value="" type="text"
                                                    class="mws-textinput" maxlength="50" />
                                                <input type="hidden" id="FatherId" name="FatherId" value="$oFormPatientRelative.FatherId" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Mother Name</label>
                                            <div class="mws-form-item">
                                                <input name="Mothername" value="$oFormPatientRelative.Mothername" type="text" class="mws-textinput"
                                                    maxlength="50" />
                                                <input type="hidden" id="MotherId" name="MotherId" value="$oFormPatientRelative.MotherId" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Marital Status</label>
                                            <div class="mws-form-item">
                                                $DdMaritalStatus
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Education</label>
                                            <div class="mws-form-item">
                                                $DdEducation
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Religion</label>
                                            <div class="mws-form-item">
                                                $DdReligion
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Spouse Name</label>
                                            <div class="mws-form-item">
                                                <input id="SpouseName" name="Spousename" value="$oFormPatientRelative.Spousename"
                                                    type="text" class="mws-textinput" maxlength="50" />
                                                <input type="hidden" id="SpouseId" name="SpouseId" value="$oFormPatientRelative.SpouseId" />
                                            </div>
                                        </div>
                                    </div>
                                </div>
                            </div>
                            <h3>
                                <a href="#">Payer</a></h3>
                            <div class="mws-accordion-995">
                                <div class="grid_4">
                                    <h5>
                                        Primary</h5>
                                    <div class="mws-form-inline">
                                        <div class="mws-form-row">
                                            <label>
                                                Payer Name</label>
                                            <div class="mws-form-item">
                                                <div class="mws-form-cols clearfix">
                                                    <div class="mws-form-col-6-8 alpha">
                                                        <div class="mws-form-item">
                                                            <input id="PrimaryPayerName" name="PrimaryPayerName" value="$oFormPrimaryPayer.PrimaryPayerName"
                                                                type="text" class="mws-textinput" maxlength="50" readonly="readonly" style="background-color: #F2F2F2;"/>
                                                            <input id="PrimaryPayerId" name="PrimaryPayerId" value="$oFormPrimaryPayer.PrimaryPayerId"
                                                                type="hidden" />
                                                                <input type="hidden" id="HiddenPrimaryBankInsuranceId" name="HiddenPrimaryBankInsuranceId" value="$oFormPrimaryPayer.HiddenPrimaryBankInsuranceId" />
                                                               
                                                            <input type="hidden" id="HiddenPayerStatus"/>
                                                        </div>
                                                    </div>
                                                    <div class="mws-form-col-2-8">
                                                        <div class="mws-form-item">
                                                            <input type="button" class="mws-button green small" name="ButtonSearchPrimaryPayer"
                                                                value="   Search   " onclick="OpenPopUpPrimaryPayer()" style="margin-top: 0;
                                                                width: 77px;" />
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Payer Category
                                            </label>
                                            <div class="mws-form-item">
                                                <!--flag-->
                                                <input id="PrimaryPayerCategoryName" name="PrimaryPayerCategoryName" value="$oFormPrimaryPayer.PrimaryPayerCategoryName"
                                                    type="text" class="mws-textinput" maxlength="50" readonly="readonly" style="background-color: #F2F2F2;"/>
                                                <input id="PrimaryPayerCategoryId" name="PrimaryPayerCategoryId" value="$oFormPrimaryPayer.PrimaryPayerCategoryId"
                                                    type="hidden" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Phone</label>
                                            <div class="mws-form-item">
                                                <input id="PrimaryPayerPhoneNumber" name="PrimaryPayerPhoneNumber" value="$oFormPrimaryPayer.PrimaryPayerPhoneNumber"
                                                    type="text" class="mws-textinput" maxlength="20" readonly="readonly" style="background-color: #F2F2F2;"/>
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Valid From</label>
                                            <div class="mws-form-item small">
                                                <input id="PrimaryPayerValidFrom" name="PrimaryPayerValidFrom" value="$oFormPrimaryPayer.PrimaryPayerValidFrom"
                                                    type="text" class="mws-textinput mws-datepicker-range2020 indonesianDate" maxlength="10" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Valid To</label>
                                            <div class="mws-form-item small">
                                                <input id="PrimaryPayerValidTo" name="PrimaryPayerValidTo" value="$oFormPrimaryPayer.PrimaryPayerValidTo"
                                                    type="text" class="mws-textinput mws-datepicker-range2020 indonesianDate" maxlength="10" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Insurance Number</label>
                                            <div class="mws-form-item">
                                                <input id="PrimaryPayerInsuranceNumber" name="PrimaryPayerInsuranceNumber" value="$oFormPrimaryPayer.PrimaryPayerInsuranceNumber"
                                                    type="text" class="mws-textinput" maxlength="50" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Fax</label>
                                            <div class="mws-form-item">
                                                <input id="PrimaryPayerFax" name="PrimaryPayerFax" value="$oFormPrimaryPayer.PrimaryPayerFax"
                                                    type="text" class="mws-textinput" maxlength="50" readonly="readonly" style="background-color: #F2F2F2;"/>
                                            </div>
                                        </div>
                                    </div>
                                </div>
                                <div class="grid_4">
                                    <div class="grid_4">
                                        <h5>
                                            <br />
                                        </h5>
                                    </div>
                                    <div class="grid_4">
                                        <label>
                                        </label>
                                    </div>
                                    <div class="clear">
                                    </div>
                                    <div class="mws-form-inline">
                                        <div class="mws-form-row">
                                            <label>
                                                Address</label>
                                            <div class="mws-form-item">
                                                <textarea name="PrimaryPayerAddressDesc" id="PrimaryPayerAddressDesc" cols="20" rows="1" readonly="readonly" style="background-color: #F2F2F2;">$oFormPrimaryPayer.PrimaryPayerAddressDesc</textarea>
                                                <input type="hidden" id="HiddenPrimaryPayerAddressId" name="HiddenPrimaryPayerAddressId"
                                                    value="$oFormPrimaryPayer.HiddenPrimaryPayerAddressId" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <input type="checkbox" id="CheckBoxPrimaryIsEmployee" name="CheckBoxPrimaryIsEmployee" />
                                            <input type="hidden" id="HiddenPrimaryIsEmployee" name="HiddenPrimaryIsEmployee"
                                                value="$oFormPrimaryPayer.HiddenPrimaryIsEmployee" />
                                            <label>
                                                Employee</label>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Employee ID</label>
                                            <div class="mws-form-item">
                                                <input id="PrimaryPayerEmployeeId" name="PrimaryPayerEmployeeId" value="$oFormPrimaryPayer.PrimaryPayerEmployeeId"
                                                    type="text" class="mws-textinput" readonly="true" maxlength="50" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <div class="mws-form-item" align="right">
                                                <br />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <div class="mws-form-item" align="right">
                                                <input name="buttonResetPrimaryPayer" id="button1" type="button" value="Reset Primary Payer"
                                                    class="mws-button gray" onclick="ResetPrimaryPayer()" />
                                            </div>
                                        </div>
                                    </div>
                                </div>
                                <hr />
                                <div class="grid_4">
                                    <h5>
                                        Secondary
                                    </h5>
                                    <div class="mws-form-inline">
                                        <div class="mws-form-row">
                                            <label>
                                                Payer Name</label>
                                            <div class="mws-form-item">
                                                <div class="mws-form-cols clearfix">
                                                    <div class="mws-form-col-6-8 alpha">
                                                        <div class="mws-form-item">
                                                            <input id="SecondaryPayerName" name="SecondaryPayerName" value="$oFormSecondaryPayer.SecondaryPayerName"
                                                                type="text" class="mws-textinput" maxlength="50" onclick="return SecondaryPayerName_onclick()" readonly="readonly" style="background-color: #F2F2F2;"/>
                                                            <input id="SecondaryPayerId" name="SecondaryPayerId" value="$oFormSecondaryPayer.SecondaryPayerId"
                                                                type="hidden" />

                                                                <input type="hidden" id="HiddenSecondaryBankInsuranceId" name="HiddenSecondaryBankInsuranceId" value="$oFormSecondaryPayer.HiddenSecondaryBankInsuranceId" />
                                                               
                                                        </div>
                                                    </div>
                                                    <div class="mws-form-col-2-8">
                                                        <div class="mws-form-item">
                                                            <input type="button" class="mws-button green small" name="ButtonSearchSecondaryPayer"
                                                                value="   Search   " onclick="OpenPopUpSecondaryPayer()" style="margin-top: 0;
                                                                width: 77px;" />
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Payer Category
                                            </label>
                                            <div class="mws-form-item">
                                                <!--flag-->
                                                <input id="SecondaryPayerCategoryName" name="SecondaryPayerCategoryName" value="$oFormSecondaryPayer.SecondaryPayerCategoryName"
                                                    type="text" class="mws-textinput" maxlength="50" readonly="readonly" style="background-color: #F2F2F2;"/>
                                                <input id="SecondaryPayerCategoryId" name="SecondaryPayerCategoryId" value="$oFormSecondaryPayer.SecondaryPayerCategoryId"
                                                    type="hidden" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Phone</label>
                                            <div class="mws-form-item">
                                                <input id="SecondaryPayerPhoneNumber" name="SecondaryPayerPhoneNumber" value="$oFormSecondaryPayer.SecondaryPayerPhoneNumber"
                                                    type="text" class="mws-textinput" maxlength="20" readonly="readonly" style="background-color: #F2F2F2;"/>
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Valid From</label>
                                            <div class="mws-form-item small">
                                                <input id="SecondaryPayerValidFrom" name="SecondaryPayerValidFrom" value="$oFormSecondaryPayer.SecondaryPayerValidFrom"
                                                    type="text" class="mws-textinput mws-datepicker-range2020 indonesianDate" maxlength="10" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Valid To</label>
                                            <div class="mws-form-item small">
                                                <input id="SecondaryPayerValidTo" name="SecondaryPayerValidTo" value="$oFormSecondaryPayer.SecondaryPayerValidTo"
                                                    type="text" class="mws-textinput mws-datepicker-range2020 indonesianDate" maxlength="10" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Insurance Number</label>
                                            <div class="mws-form-item">
                                                <input id="SecondaryPayerInsuranceNumber" name="SecondaryPayerInsuranceNumber" value="$oFormSecondaryPayer.SecondaryPayerInsuranceNumber"
                                                    type="text" class="mws-textinput" maxlength="50" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Fax</label>
                                            <div class="mws-form-item">
                                                <input id="SecondaryPayerFax" name="SecondaryPayerFax" value="$oFormSecondaryPayer.SecondaryPayerFax"
                                                    type="text" class="mws-textinput" maxlength="50" readonly="readonly" style="background-color: #F2F2F2;" />
                                            </div>
                                        </div>
                                    </div>
                                </div>
                                <div class="grid_4">
                                    <div class="grid_4">
                                        <h5>
                                            <br />
                                        </h5>
                                    </div>
                                    <div class="grid_4">
                                        <label>
                                        </label>
                                    </div>
                                    <div class="clear">
                                    </div>
                                    <div class="mws-form-inline">
                                        <div class="mws-form-row">
                                            <label>
                                                Address</label>
                                            <div class="mws-form-item">
                                                <textarea name="SecondaryPayerAddressDesc" id="SecondaryPayerAddressDesc" cols="20"
                                                    rows="2" readonly="readonly" style="background-color: #F2F2F2;">$oFormSecondaryPayer.SecondaryPayerAddressDesc</textarea>
                                                <input type="hidden" id="HiddenSecondaryPayerAddressId" name="HiddenSecondaryPayerAddressId"
                                                    value="$oFormSecondaryPayer.HiddenSecondaryPayerAddressId" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <input type="checkbox" id="CheckBoxSecondaryIsEmployee" name="CheckBoxSecondaryIsEmployee" />
                                            <input type="hidden" id="HiddenSecondaryIsEmployee" value="$oFormSecondaryPayer.HiddenSecondaryIsEmployee" />
                                            <label>
                                                Employee</label>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Employee ID</label>
                                            <div class="mws-form-item">
                                                <input id="SecondaryPayerEmployeeId" name="SecondaryPayerEmployeeId" value="$oFormSecondaryPayer.SecondaryPayerEmployeeId"
                                                    type="text" class="mws-textinput" readonly="true" maxlength="50" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <div class="mws-form-item" align="right">
                                                <br />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <div class="mws-form-item" align="right">
                                                <input name="buttonResetSecondaryPayer" id="buttonResetSecondaryPayer" type="button"
                                                    value="Reset Secondary Payer" class="mws-button gray" onclick="ResetSecondaryPayer()" />
                                            </div>
                                        </div>
                                    </div>
                                </div>
                                <hr />
                                <div class="grid_4">
                                    <h5>
                                        Tertiery</h5>
                                    <div class="mws-form-inline">
                                        <div class="mws-form-row">
                                            <label>
                                                Payer Name</label>
                                            <div class="mws-form-item">
                                                <div class="mws-form-cols clearfix">
                                                    <div class="mws-form-col-6-8 alpha">
                                                        <div class="mws-form-item">
                                                            <input id="TertieryPayerName" name="TertieryPayerName" value="$oFormTertieryPayer.TertieryPayerName"
                                                                type="text" class="mws-textinput" maxlength="50" readonly="readonly" style="background-color: #F2F2F2;"/>
                                                            <input id="TertieryPayerId" name="TertieryPayerId" value="$oFormTertieryPayer.TertieryPayerId"
                                                                type="hidden" />

                                                                <input type="hidden" id="HiddenTertieryBankInsuranceId" name="HiddenTertieryBankInsuranceId" value="$oFormTertieryPayer.HiddenTertieryBankInsuranceId" />
                                                               
                                                        </div>
                                                    </div>
                                                    <div class="mws-form-col-2-8">
                                                        <div class="mws-form-item">
                                                            <input type="button" class="mws-button green small" name="ButtonSearchTertieryPayer"
                                                                value="   Search   " onclick="OpenPopUpTertieryPayer()" style="margin-top: 0;
                                                                width: 77px;" />
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Payer Category
                                            </label>
                                            <div class="mws-form-item">
                                                <!--flag-->
                                                <input id="TertieryPayerCategoryName" name="TertieryPayerCategoryName" value="$oFormTertieryPayer.TertieryPayerCategoryName"
                                                    type="text" class="mws-textinput" maxlength="50" readonly="readonly" style="background-color: #F2F2F2;"/>
                                                <input id="TertieryPayerCategoryId" name="TertieryPayerCategoryId" value="$oFormTertieryPayer.TertieryPayerCategoryId"
                                                    type="hidden" /></div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Phone</label>
                                            <div class="mws-form-item">
                                                <input id="TertieryPayerPhoneNumber" name="TertieryPayerPhoneNumber" value="$oFormTertieryPayer.TertieryPayerPhoneNumber"
                                                    type="text" class="mws-textinput" maxlength="20" readonly="readonly" style="background-color: #F2F2F2;"/>
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Valid From</label>
                                            <div class="mws-form-item small">
                                                <input id="TertieryPayerValidFrom" name="TertieryPayerValidFrom" value="$oFormTertieryPayer.TertieryPayerValidFrom"
                                                    type="text" class="mws-textinput mws-datepicker-range2020 indonesianDate" maxlength="10" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Valid To</label>
                                            <div class="mws-form-item small">
                                                <input id="TertieryPayerValidTo" name="TertieryPayerValidTo" value="$oFormTertieryPayer.TertieryPayerValidTo"
                                                    type="text" class="mws-textinput mws-datepicker-range2020 indonesianDate" maxlength="10" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Insurance Number</label>
                                            <div class="mws-form-item">
                                                <input id="TertieryPayerInsuranceNumber" name="TertieryPayerInsuranceNumber" value="$oFormTertieryPayer.TertieryPayerInsuranceNumber"
                                                    type="text" class="mws-textinput" maxlength="50" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Fax</label>
                                            <div class="mws-form-item">
                                                <input id="TertieryPayerFax" name="TertieryPayerFax" value="$oFormTertieryPayer.TertieryPayerFax"
                                                    type="text" class="mws-textinput" maxlength="50" readonly="readonly" style="background-color: #F2F2F2;"/>
                                            </div>
                                        </div>
                                    </div>
                                </div>
                                <div class="grid_4">
                                    <div class="grid_4">
                                        <h5>
                                            <br />
                                        </h5>
                                    </div>
                                    <div class="grid_4">
                                        <label>
                                        </label>
                                    </div>
                                    <div class="clear">
                                    </div>
                                    <div class="mws-form-inline">
                                        <div class="mws-form-row">
                                            <label>
                                                Address</label>
                                            <div class="mws-form-item">
                                                <textarea name="TertieryPayerAddressDesc" id="TertieryPayerAddressDesc" cols="20"
                                                    rows="2" readonly="readonly" style="background-color: #F2F2F2;">$oFormTertieryPayer.TertieryPayerAddressDesc</textarea>
                                                <input type="hidden" id="HiddenTertieryPayerAddressId" name="HiddenTertieryPayerAddressId"
                                                    value="$oFormTertieryPayer.HiddenTertieryPayerAddressId" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <input type="checkbox" id="CheckBoxTertieryIsEmployee" name="CheckBoxTertieryIsEmployee" />
                                            <input type="hidden" id="HiddenTertieryIsEmployee" value="$oFormTertieryPayer.HiddenTertieryIsEmployee" />
                                            <label>
                                                Employee</label>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Employee ID</label>
                                            <div class="mws-form-item">
                                                <input id="TertieryPayerEmployeeId" name="TertieryPayerEmployeeId" value="$oFormTertieryPayer.TertieryPayerEmployeeId"
                                                    type="text" class="mws-textinput" readonly="true" maxlength="50" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <div class="mws-form-item" align="right">
                                                <br />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <div class="mws-form-item" align="right">
                                                <input name="buttonResetTertieryPayer" id="buttonResetTertieryPayer" type="button"
                                                    value="Reset Tertiery Payer" class="mws-button gray" onclick="ResetTertieryPayer()" />
                                            </div>
                                        </div>
                                    </div>
                                </div>
                            </div>
                            <h3>
                                <a href="#">Family</a></h3>
                            <div class="mws-accordion-400">
                                <div class="grid_4">
                                    <div class="mws-form-inline">
                                        <div class="mws-form-row">
                                            <label>
                                                Name</label>
                                            <div class="mws-form-item">
                                                <input id="FamilyRelativeName" name="FamilyRelativeName" value="$oFormPatientRelative.FamilyRelativeName"
                                                    type="text" class="mws-textinput" maxlength="50" />
                                                <input type="hidden" id="FamilyRelativeId" name="FamilyRelativeId" value="$oFormPatientRelative.FamilyRelativeId" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Address</label>
                                            <div class="mws-form-item">
                                                <input id="FamilyRelativeAddress" name="FamilyRelativeAddress" value="$oFormPatientRelative.FamilyRelativeAddress"
                                                    type="text" class="mws-textinput" maxlength="255" />
                                                <input name="FamilyRelativeAddressId" value="$oFormPatientRelative.FamilyRelativeAddressId"
                                                    type="hidden" class="mws-textinput" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Phone</label>
                                            <div class="mws-form-item">
                                                <input name="FamilyRelativePhone" id="FamilyRelativePhone" value="$oFormPatientRelative.FamilyRelativePhone"
                                                    type="text" class="mws-textinput" maxlength="20" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Mobile Phone</label>
                                            <div class="mws-form-item">
                                                <input name="FamilyRelativeMobilephone" id="FamilyRelativeMobilephone" value="$oFormPatientRelative.FamilyRelativeMobilephone"
                                                    type="text" class="mws-textinput" maxlength="20" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Email ID</label>
                                            <div class="mws-form-item">
                                                <input name="FamilyRelativeEmail" id="FamilyRelativeEmail" value="$oFormPatientRelative.FamilyRelativeEmail"
                                                    type="text" class="mws-textinput email" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Relationship</label>
                                            <div class="mws-form-item">
                                                $DdFamilyRelative
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Note</label>
                                            <div class="mws-form-item">
                                                <textarea name="FamilyRelativeNote" id="FamilyRelativeNote" cols="20" rows="2">$oFormPatientRelative.FamilyRelativeNote</textarea>
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <div class="mws-form-item" align="right">
                                                <input name="buttonResetFamilyRelative" id="buttonResetFamilyRelative" type="button"
                                                    value="Reset Family Relative" class="mws-button gray" onclick="ResetFamilyRelative()" />
                                            </div>
                                        </div>
                                    </div>
                                </div>
                            </div>
                            <h3>
                                <a href="#">Other Contacts</a></h3>
                            <div class="mws-accordion-400">
                                <div class="grid_4">
                                    <div class="mws-form-inline">
                                        <div class="mws-form-row">
                                            <label>
                                                Name</label>
                                            <div class="mws-form-item">
                                                <input name="OtherRelativeName" id="OtherRelativeName" value="$oFormPatientRelative.OtherRelativeName"
                                                    type="text" class="mws-textinput" maxlength="50" />
                                                <input type="hidden" id="OtherRelativeId" name="OtherRelativeId" value="$oFormPatientRelative.OtherRelativeId" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Address</label>
                                            <div class="mws-form-item">
                                                <input name="OtherRelativeAddress" id="OtherRelativeAddress" value="$oFormPatientRelative.OtherRelativeAddress"
                                                    type="text" class="mws-textinput" maxlength="50" />
                                                <input name="OtherRelativeAddressId" value="$oFormPatientRelative.OtherRelativeAddressId"
                                                    type="hidden" class="mws-textinput" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Phone</label>
                                            <div class="mws-form-item">
                                                <input name="OtherRelativePhone" id="OtherRelativePhone" value="$oFormPatientRelative.OtherRelativePhone"
                                                    type="text" class="mws-textinput" maxlength="20" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Mobile Phone</label>
                                            <div class="mws-form-item">
                                                <input name="OtherRelativeMobilephone" id="OtherRelativeMobilephone" value="$oFormPatientRelative.OtherRelativeMobilephone"
                                                    type="text" class="mws-textinput" maxlength="20" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Email ID</label>
                                            <div class="mws-form-item">
                                                <input name="OtherRelativeEmail" id="OtherRelativeEmail" value="$oFormPatientRelative.OtherRelativeEmail"
                                                    type="text" class="mws-textinput email" />
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Relationship</label>
                                            <div class="mws-form-item">
                                                $DdRelative
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <label>
                                                Note</label>
                                            <div class="mws-form-item">
                                                <textarea name="OtherRelativeNote" id="OtherRelativeNote" cols="20" rows="2">$oFormPatientRelative.OtherRelativeNote</textarea>
                                            </div>
                                        </div>
                                        <div class="mws-form-row">
                                            <div class="mws-form-item" align="right">
                                                <input name="buttonResetOtherRelative" id="buttonResetOtherRelative" type="button"
                                                    value="Reset Contact" class="mws-button gray" onclick="ResetOtherRelative()" />
                                            </div>
                                        </div>
                                    </div>
                                </div>
                            </div>
                        </div>
                    </div>
                    <div class="clear15">
                    </div>
                    <div class="mws-form-inline">
                        <div class="mws-form-row">
                            <br />
                            <span style="color: #FF0000; font-size: large;">*</span><span style="color: #FF0000;">
                                : Mandatory</span>
                        </div>
                    </div>
                    <div class="mws-button-row">
                        <input name="buttonAction" id="buttonAction" type="submit" value="Submit" class="mws-button red" />
                        <input type="reset" value="Reset" class="mws-button gray" />
                    </div>
                </div>
            </div>
        </div>
        </form>
        <!-- Panels End -->
    </div>
    <!-- <div id="ajaxLoader" style="display: none;">
        <img src="${rooturl}Images/Icons/ajax-loader.gif" width=50px height=20px/>
    </div>-->
    <div id="dialog-confirm" title="Registration Confirmation" style="display: none">
        <p>
        </p>
        <p>
            <span class="ui-icon ui-icon-alert" style="float: left; margin: 2px 7px 20px 40px;">
            </span>Continue to registration process?</p>
    </div>
    <!-- Inner Container End -->
    <div id="passportDialog" style="display: none;">
        <div class="mws-form" action="#">
            <br />
            <form method="post" action="$Actionform" class="crud" id="mws-validate-passport">
            <div class="grid_2_5">
                <div class="mws-form-inline">
                    <div class="mws-panel grid_8">
                        <div class="mws-panel-header">
                            <span class="mws-i-24 i-calendar-today">Passport</span>
                        </div>
                        <div class="mws-panel-body">
                            <br />
                            <div class="mws-form-row">
                                <label>
                                    Passport</label>
                                <div class="mws-form-item large">
                                    <input type="hidden" id="PassportId" name="PassportId" value="$oFormPatientPassport.PassportId" />
                                    <input type="hidden" id="PatientPassportTypeId" name="PatientPassportTypeId" value="$oFormPatientPassport.PatientPassportTypeId" />
                                    <input class="mws-textinput" id="TextBoxPassport" name="PassportCodeValue" type="text"
                                        value="$oFormPatientPassport.PassportCodeValue" maxlength="50" />
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Issued Date</label>
                                <div class="mws-form-item large">
                                    <input class="mws-textinput mws-datepicker-range2020 indonesianDate" id="TextBoxPassportIssuedDate"
                                        name="PassportIssuedDate" type="text" value="$oFormPatientPassport.PassportIssuedDate"
                                        maxlength="10" />
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Expiry Date
                                </label>
                                <div class="mws-form-item large">
                                    <input class="mws-textinput mws-datepicker-range2020 indonesianDate" id="TextBoxPassportExpiryDate"
                                        name="PassportExpiryDate" type="text" maxlength="10" value="$oFormPatientPassport.PassportExpiryDate" />
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Issued At</label>
                                <div class="mws-form-item large">
                                    <input class="mws-textinput" id="TextBoxPassportIssuedAt" name="PassportIssuedAt"
                                        type="text" value="$oFormPatientPassport.PassportIssuedAt" maxlength="50" />
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Nationality</label>
                                <div class="mws-form-item large">
                                    <!--<input class="mws-textinput" id="TextBoxPassportNationality" name="TextBoxPassportNationality"
                                    type="text" value="" />-->
                                    $DdNationality
                                </div>
                            </div>
                            <br />
                        </div>
                    </div>
                </div>
            </div>
            <div class="grid_2_5">
                <div class="mws-form-inline">
                    <div class="mws-panel grid_8">
                        <div class="mws-panel-header">
                            <span class="mws-i-24 i-calendar-today">Visa</span>
                        </div>
                        <div class="mws-panel-body">
                            <div class="mws-form-row">
                                <br />
                                <label>
                                    Issued Me</label>
                                <div class="mws-form-item large">
                                    <input type="hidden" id="VisaId" name="VisaId" value="$oFormPatientVisa.VisaId" />
                                    <input type="hidden" id="PatientVisaTypeId" name="PatientVisaTypeId" value="$oFormPatientVisa.PatientVisaTypeId" />
                                    <input class="mws-textinput" id="TextBoxVisaIssuedMe" name="VisaIssuedMe" type="text"
                                        value="$oFormPatientVisa.VisaIssuedMe" maxlength="50" />
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Issued Date</label>
                                <div class="mws-form-item large">
                                    <input class="mws-textinput mws-datepicker-range2020 indonesianDate" id="TextBoxVisaIssuedDate"
                                        name="VisaIssuedDate" type="text" value="$oFormPatientVisa.VisaIssuedDate" maxlength="10" />
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Expiry Date
                                </label>
                                <div class="mws-form-item large">
                                    <input class="mws-textinput mws-datepicker-range2020 indonesianDate" id="TextBoxVisaExpiryDate"
                                        name="VisaExpiryDate" type="text" value="$oFormPatientVisa.VisaExpiryDate" maxlength="10" />
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Issued By</label>
                                <div class="mws-form-item large">
                                    <input class="mws-textinput" id="TextBoxVisaIssuedBy" name="VisaIssuedBy" type="text"
                                        value="$oFormPatientVisa.VisaIssuedBy" maxlength="50" />
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Foreigner</label>
                                <div class="mws-form-item large">
                                    <input type="checkbox" id="CheckBoxVisaForeigner" name="CheckBoxVisaForeigner" />
                                    <input type="hidden" id="VisaIsForeigner" name="VisaIsForeigner" value="$oFormPatientVisa.VisaIsForeigner" />
                                </div>
                            </div>
                            <br />
                        </div>
                    </div>
                </div>
            </div>
            <div class="grid_2_5">
                <div class="mws-form-inline">
                    <div class="mws-panel grid_8">
                        <div class="mws-panel-header">
                            <span class="mws-i-24 i-calendar-today">Work Permit</span>
                        </div>
                        <div class="mws-panel-body">
                            <div class="mws-form-row">
                                <br />
                                <label>
                                    Work Permit ID</label>
                                <div class="mws-form-item large">
                                    <input type="hidden" id="WorkPermitId" name="WorkPermitId" value="$oFormPatientWorkPermit.WorkPermitId" />
                                    <input type="hidden" id="PatientWorkPermitTypeId" name="PatientWorkPermitTypeId"
                                        value="$oFormPatientWorkPermit.PatientWorkPermitTypeId" />
                                    <input class="mws-textinput" id="TextBoxWorkPermitId" name="WorkPermitCodeValue"
                                        type="text" value="$oFormPatientWorkPermit.WorkPermitCodeValue" maxlength="50" />
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Issued Date</label>
                                <div class="mws-form-item large">
                                    <input class="mws-textinput mws-datepicker-range2020 indonesianDate" id="TextBoxWorkPermitIssuedDate"
                                        name="WorkPermitIssuedDate" type="text" value="$oFormPatientWorkPermit.WorkPermitIssuedDate"
                                        maxlength="10" />
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Expiry Date
                                </label>
                                <div class="mws-form-item large">
                                    <input class="mws-textinput mws-datepicker-range2020 indonesianDate" id="TextBoxWorkPermitExpiryDate"
                                        name="WorkPermitExpiryDate" type="text" value="$oFormPatientWorkPermit.WorkPermitExpiryDate"
                                        maxlength="10" />
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    Issued By</label>
                                <div class="mws-form-item large">
                                    <input class="mws-textinput" id="TextBoxWorkPermitIssuedBy" name="WorkPermitIssuedBy"
                                        type="text" value="$oFormPatientWorkPermit.WorkPermitIssuedBy" maxlength="50" />
                                </div>
                            </div>
                            <div class="mws-form-row">
                                <label>
                                    &nbsp</label>
                                <div class="mws-form-item large">
                                    <br />
                                </div>
                            </div>
                            <br />
                        </div>
                    </div>
                </div>
            </div>
            
            <div class="clear15">
            </div>
            <div class="mws-button-row">
                <input name="buttonSubmitPassport" id="buttonSubmitPassport" type="button" value="Submit"
                    class="mws-button red" />
                <input name="buttonCancelPassport" id="buttonCancelPassport" type="reset" value="Cancel"
                    class="mws-button gray" />
            </div>
            </form>
        </div>
    </div>
#parse("partials/footer.html")